Power, responsibility, and blame within models of psychological distress

When we face difficulties or are in distress we need to be able to make sense of how we feel. What ideas are available to us? What ideas do those offering to help us suggest? How do these ideas shape the relationship between helper and helped? To what extent do they empower us to understand ourselves and solve our problems?

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There is an obviously close relationship between power and responsibility. The more power one has the more responsibility one has. The opposite is also true; the less responsibility one has the less power one has. How does this apply to different ways of describing psychological distress? If you don’t have any responsibility for your distress then you are not to blame for it. But it also seems to follow that you don’t have the power to overcome it. At first sight it seems that you can’t have the power to change your distress without being to blame for it in the first place. Clearly blaming people for their psychological distress would be a bad place to start if you wanted to help them. In fact most models of psychological distress are very careful not to blame the person. They do this by suggesting we are not responsible for our psychological problems and in the process they inevitably disempower us to a greater or lesser extent. This raises the question whether there is a way of thinking about psychological distress that empowers without blaming?Can we, in some way, have responsibility without being to blame?

Psychiatry and Psychology frequently make claims to being scientific. However, in spite of the fact that they both deal with human distress, they have very different ways of thinking about the causes of psychological distress. If there is science involved the science is what Thomas Kuhn, in his book The Structure of Scientific Revolutions, termed pre-paradigmatic. There is no widespread consensus on the ideas we use to understand the causes of psychological distress.

If there is some science in attempts to understand psychological distress it is generally different from the sort of science in the hard sciences such as physics and chemistry. The exception to this might be the biological model of psychiatry. This clings to the hope that biological and genetic factors might eventually be found to fully explain various forms of psychological distress. If this turned out to be the case it would indeed make psychiatry a science like physics and chemistry. (Robert Whitaker in Anatomy of an Epidemic gives an interesting historical account of this biological model.)

Any examples of psychological distress that were established as due to genetic and biological factors would justifiably be regarded as illnesses. These mental illnesses would be seen in much the same way as purely physical illnesses. Patients would rightfully see their distress as caused by and totally explained by their diagnosis. In terms of power, responsibility and blame this would have clear implications for both the sufferer and the helper. The sufferer would be seen as bearing little or no responsibility and no blame for their illness. It follows also that they would have little power to help themselves feel better. They would have to seek expert medical help which would first involve being given a psychiatric diagnosis. They would then follow advice which would most probably be to take prescribed medication. They would be a patient (one who waits) and the words ‘treatment’ and ‘compliance’ capture the passivity expected of them.

This way of describing psychological distress creates a clear power differential and ‘distance’ between doctor and patient. The doctor can operate from the comfortable position of being the expert who knows what ‘illness’ the person is ‘suffering from’ and how it needs to be ‘treated’. On the other hand the patient may experience a mixture of relief and concern. Relief because they know what is ‘wrong with’ them and concern because they cannot predict how and when they might become distressed. They have to accept that in some way they have become ill and since this is due to a mental illness their behaviour and feelings may be unpredictable and abnormal. They must rely on the doctor and submit themselves to the treatment prescribed.

Many would argue that this strict biological model has not been established and is unlikely ever to be so. At present perhaps the majority of mental health practitioners rely on the idea of mental illness but do not necessarily believe in the strict biological model. Instead they argue for a biopsychosocial model of distress where mental illness results from the interaction of biological, psychological and social factors. Exactly how the various factors in this model interact is usually left unspecified. As above for the strict biological model, those that recognise the biopsychosocial model would usually adopt the position that the person in distress bears little or no responsibility or blame for their distress. Again, as with the strict biological model, the distressed person is usually termed a ‘patient’ and following proper diagnosis they are offered medication and on occasions some form of psychological help. The latter is usually described as psychological ‘treatment’.

As with the strict biological model this softer medical model sees the power and responsibility as residing in the hands of the professional. It does not significantly empower the distressed person to change their situation. Again the power differential and ‘distance’ between professional and patient is quite marked.

While medical models remain the dominant approach, psychiatric diagnosis has been heavily criticised by some especially in its latest incarnation, DSM 5. An alternative to diagnosis that seems to be increasingly discussed is formulation. In fact we really need to talk about psychological formulation as a distinct alternative to psychiatric diagnosis as the idea of formulation has been incorporated, albeit in a psychiatric form into psychiatric thinking. In a blog on Mad in America Lucy Johnstone, lead author of the BPS guidelines on formulation, points out that “the term ‘formulation’ appears in several places in the UK training curriculum for psychiatrists” and quoting from the Royal College of Psychiatrists she writes that psychiatrists are required to ‘demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses’.

Psychological formulation is described by The British Psychological Society as “a description of a person’s difficulties, agreed between the psychologist and client, which is based in psychological evidence and informs the intervention”. This approach does seem to offer a distinct alternative to the medical model.

However, in the same blog on Mad in America Lucy Johnstone offers what she describes as a “one-size-fits-all” formulation for long-term service users;

Service user X has unmet attachment needs and unresolved trauma from their early life. X tries to meet these through the psychiatric services, but fails, since services are not set up to do this. Still needy, but unable to achieve enough emotional security to move on, X ends up trading ‘symptoms’ for whatever psychiatric care is on offer. Staff are initially sympathetic but become increasingly frustrated at X’s lack of progress. The resulting dynamic may end up repeating X’s early experiences of neglect, rejection or abuse. Both parties become stuck, frustrated and demoralised in this vicious circle.

It is not clear that many long-term service users would necessarily agree with this particular formulation. Psychological formulations can be written from very different psychological perspectives. In particular, different psychological models place very different emphases on the role of past events. Possibly the majority of psychological formulations focus, among other things, on the life experiences of the individual. They typically talk about the individual’s history and issues such as trauma and abuse. A core idea is that the individual has not processed or resolved events and circumstances from their past. This is important as clients will not infrequently be predisposed to assume that past events are the active causes of their current distress. As a result they will often see themselves as the relatively passive victim of their past. Their focus will then tend to be on what has happened to them in the past. In terms of the ideas we use to understand distress this can be seen as swapping one deterministic model for another; from the biological to the biographical.

Within this perspective of psychological formulations the distressed person is often referred to as a ‘client’ rather than a ‘patient’. While they are not necessarily seen as mentally ill they are usually described as ‘suffering from’ or ‘having’ a particular ‘condition’ or ‘disorder’. They are not seen as responsible for the origin of their distress and are not to blame because the cause of their distress is seen as the events and circumstances of their lives. The psychological help that is offered is invariably still referred to as ‘treatment’.As a result, while this is not a medical model it has some of the same implications for where the power resides and the role of the distressed person.

As with the medical model clients could be forgiven for thinking that while labels such as ‘condition’ and ‘disorder’ absolve them from responsibility these labels appear to carry a lurking insinuation of abnormality. So while they explicitly absolve the person of responsibility, they can like the more medical models reinforce stigma.

Furthermore, on one side of the power differential therapists frequently emphasise their professionalism, training and expertise. In order to add the authority of science to their therapy they often also emphasise that their clinical practices are evidence-based. Presenting themselves and their practice in these ways, while entirely reasonable from one perspective, also tends to shape the power relationship between therapist and client. As a result there can still be a significant power differential and ‘distance’ between professional and client. This can, perhaps, be seen in the nervousness with which many clients will approach what is often called the ‘assessment session’ in the ‘consulting’ room. These terms tend to reinforce the relative passivity of the client.

One of the most talked about therapeutic approaches that uses formulation is Cognitive Behaviour therapy (CBT). The British Association of Behavioural and Cognitive Therapies (BABCP), which claims on its website that it is the lead organisation for CBT in the UK, states that “the therapist and client work together in changing the client’s behaviours, or their thinking patterns, or both of these”. This statement holds out the hope of a radical alternative to the medical model. The phrase “work together” suggests a fairly equal, collaborative relationship between therapist and client aimed at changing the client’s current thinking and behaviour.

However, the BABCP website also states that CBT “works effectively in treating depression” and that it is “recommended by NICE (National Institute for Clinical Excellence) for treatment of anxiety disorders”. The BABCP also states that CBT is “mainly concerned with how you think and act now, instead of looking at and getting help with difficulties in your past”. It is not clear what this means about how we should think of past difficulties. Are past difficulties too difficult to deal with? Is CBT not up to the job? Do past difficulties require some deeper, more complex therapy? Or are past difficulties important only to the extent that they are now part of our current thinking and acting?

Other organisations that people might well turn to for a description of CBT are The Royal College of Psychiatrists (RCPsych) and NHS Choices. The RCPsych website states that “The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.” There is still some ambiguity in this regarding the causal nature of past events. It is not clear whether past difficulties are the cause of distress or whether the way the person is now thinking about past events is the cause. Another statement on the same site seems to suggest the former interpretation with the following statements “there is always a risk that the anxiety and depression will return” and “CBT can help you control your symptoms”. These statements appear to suggest that in spite of a person’s current thinking there is some ‘condition’ or ‘disorder’ lurking in the background. These statements have more than a hint of the medical model about them. In a similar vein the NHS Choices website states that “CBT cannot remove your problems but it can help you deal with them in a more positive way.”

These statements can seem to carry the implication that we are the victims of our past and that CBT is little more than a sticking plaster. They can seem to allude to something behind the symptoms that is ongoing and that is to do with the past. Overall, they leave a somewhat confused impression about the causes of distress.

Of course, not all CBT therapists would agree with the statements on these websites. However, in practice many do explore the client’s history and in doing so can create the inference that the person is experiencing distress because of these past events and circumstances. Even when the therapist does not believe this the client may be predisposed to draw this conclusion because this is a dominant idea in the culture. This can leave the person with the impression that they are initially the passive victim of their circumstances (often reinforced by the description of their distress as ‘suffering from’ such and such a ‘condition’ or ‘disorder’) but that they are now expected to be the active agent in their recovery.

In general CBT tries to set out a collaborative relationship so that “therapist and client work together”. However, a number of issues can undermine this intention and can create a power differential between therapist and client reducing the extent to which the client is empowered. References to ‘treatment’ and the client ‘suffering from’ a ‘disorder’ can to many clients seem to place them in a passive and stigmatised role. Ambiguity about the role of the client’s history can add to their passivity and their pessimism about the future if they assume past events are the cause of their distress. Clients are usually required to follow recommended (prescribed) therapeutic techniques, and to undertake ‘homework’ tasks and report back on these. The fact that they can sometimes do these half-heartedly or at the last moment suggests they are ‘doing as they are told’ rather than fully embracing their responsibility for overcoming their problems.

The techniques prescribed are often presented as evidenced–based and as being the result of years of painstaking research. Describing CBT as ‘treatment’ can suggest that the techniques ‘work’ and have little to do with the client’s understanding and commitment. Clients who do not make progress will often explain this by saying that ‘CBT didn’t work’. This suggests that in spite of any efforts the therapist had made the client had the expectation that they only had to submit themselves passively to the ‘treatment’ to feel better. This reminds us that the whole business of therapy is conducted in a cultural framework of ideas such as ‘treatment’ and clients ‘suffering from’ ‘disorders’ and ‘conditions’.

Within CBT the emphasis on the therapist’s high level of expertise, ‘treatment’, ‘techniques’, ‘homework’ and reporting back can add further to the power differential and the client’s passivity.

[Interestingly, the evidence base of CBT is emphasised in spite of the fact that a meta-analysis of 115 studies concluded that “We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy”. (Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). In Review A Meta-Analysis of Cognitive-Behavioural Therapy for Adult Depression, Alone and in Comparison With Other Treatments. Canadian journal of psychiatry, 58(7).]

CBT (and most other approaches) do their best to avoid any insinuation of blaming the client. As a result it appears to use two ideas about causation; firstly absolving individuals of any responsibility for having a problem in the first place (this can be achieved by blaming the client’s history); secondly encouraging the client to take responsibility for changing their thoughts and behaviour. Is this an awkward and illogical contradiction? Perhaps, this is partly why the descriptions on the websites quoted above seem to present a confused model.

There might, of course, be a good reason why this apparent contradiction arises. Perhaps, it is naïve to ignore the economic and professional context in which therapy takes place. Therapists need both expertise and clients with problems. It is easy to assume that if their expertise can be described as an expert technology as opposed to a form of intelligent common sense this will support their services. There can, therefore, be a temptation for some (and especially professional organisations who protect their members interests) to enhance the expertise of their members and to offer definitions of distress and therapy that create or support a perceived need for expert services. Furthermore, therapists do not want to upset their potential clients by telling them they are responsible for their distress. If we were to start by doing this clients may well assume this meant they are in some way to blame. Describing distress in a way that does not see the client as responsible might, therefore, seem to be an essential starting point. The awkward contradiction of absolving the client for having the problem but stressing their agency in overcoming it achieves this. While this may involve some subtle disempowerment of the client it can enhance the power of the therapist.

However, if we can solve our distress by changing our thoughts and behaviour does this logically tell us something about the nature and causes of distress? If we can reduce our distress by changing our current thoughts and behaviour does this suggest that it is our active, ongoing thoughts and behaviour that are the problem in the first place?

Should we conclude that we have an active role in creating our distress? To some this may seem a shocking idea at first sight. Certainly, if we want to offer help to a distressed person it seems to present us with a difficulty. We clearly need to start by recognising and validating the client’s experience of distress. Can this be done without offering or seeming to agree with a description of distress that undermines the client’s responsibility and power?

Polly Young-Eisendrath in a chapter entitled “What suffering teaches” in The Couch and The Tree writes “without the capacity to see how we create a lot of our own difficulties, we are morally and spiritually adrift on all levels of existence”.

Perhaps, the key to understanding our part in our distress lies in recognising that what is important is not simply the events in our past but the way we have reacted to these. If we do not see the difference between the events and our reactions to them we are likely to carry our reactions forward into our current thinking and behaving without seeing how this affects our feelings and quality of life.

Our reactions to events and circumstances are essentially personal, although often shaped imperceptibly and substantially by those around us and the culture we live in. Our reactions are driven by our expectations, choices, values, judgements, goals etc. These are all fundamentally psychological issues in a way that events and circumstances are not. Of course many psychological approaches including CBT recognise these issues when encouraging people to overcome their difficulties; it couldn’t be otherwise. However, they do not necessarily present them as part of the cause of our distress and for which, therefore, the individual has some responsibility.

So a problem remains; can the idea of personal responsibility in the development of distress be conveyed in a way that allows distressed people to hear it? Is there a way of describing how as individuals we have a role in bringing about our own distress but that at the same time allows us to see why we should not blame ourselves? If this can be done we would fundamentally empower ourselves. We would have a clearer understanding of the psychology of distress and we would have a sharp sense of our power to overcome it.

Might we be able to achieve this if we started by simply recognising what complex creatures we are? Perhaps, we are not the rational creatures we sometimes like to think we are. Two things stand out. Firstly, although our reactions to events and circumstances are full of judgements, expectations, hopes and fears etc we are rarely aware of these aspects of our thinking.We see the world from particular value-based perspectives. We have our own theories of how things should be; our own standards and ideas. We are constantly interested in how things will work out for us and those we are close to. The way these issues are embedded in our thinking inevitably colours our experience and feelings; for good and bad.

The second thing that stands out is that even when we are aware of our particular values and perspectives and how they can lead to us feeling distressed we can find it very difficult to change our thoughts. We are creatures of habit and many of these habits are deeply ingrained.

So, much of the time we simply do not know what we are thinking. Even when we can glimpse it we can find it difficult to stop or stick to alternative less distressing ideas and judgements.

This suggests it would be helpful if we stopped thinking of ourselves as biological machines whose brain chemicals are driving our experience. And it would be equally helpful if we stopped seeing ourselves as victims of our early experience and the difficult and challenging events in our lives. Instead it would be helpful if we had a clearer understanding of the importance and complexity of our in-the-moment thinking.

The following is an outline of some ideas that might allow us to accept some responsibility for our distress but without blaming ourselves.

Psychological distress arises from the way we are thinking and behaving at the time. It is hard for us to see this because our thinking can be complex and very detailed and we are not easily aware of much of the detail. The societies we live in do not often encourage us to pay attention to how we are thinking and how we are behaving as a result. At the same time there are many vested interests that encourage us to think we are as we are because of our genes, our personality, our life history, our early childhood etc. This distracts us from the importance of how we are making sense of things and how we are thinking now.

Much of our thinking involves hopes, fears, expectations, judgements etc. These are essentially subjective and matters of opinion. It is these aspects of our thinking that generates our emotions.

We are creatures of habit. Most of the time habits serve us well as they allow us to do complex tasks with less effort. Habits are useful servants but they can be cruel masters. It takes time and patience to change unhelpful habits.

While life is both rewarding and challenging we can be faced with situations that most of us find difficult. This is because we share many of our hopes, expectations and values. We are frequently faced with situations that challenge our established habits of thinking and our hopes and attachments. Some distress is therefore inevitable. This is especially the case if the changes are unexpected or sudden change. These disrupt our lives. We have to try to adapt to the changes life brings throughout our lives. Seneca advised “for as long as we live, keep learning how to live”.

We are social animals and easily concerned about ourselves and especially what others might think of us and under some circumstances whether we are “normal”. Many societies have specific and often oppressive ideas about what it means to be different/abnormal. If we judge that something about us is not as we assume “it should be” it is easy to develop a vicious cycle of concerned thinking that is full of distress with its attendant uncomfortable sensations and behaviour.

We tend to use ideas and ways of thinking about our distress that are the dominant ones in the culture. Perhaps, the most common of these is that our feelings are caused by the situations and circumstances of our lives. This is essentially not psychological. It distracts us from recognising the importance and complexity of our thinking with all its subjective richness of personal values, hopes, expectations attachments etc. Much of the time we have little idea of how we create our own distress. This is understandable because of the societies we live in. The fact that so many people experience ongoing psychological distress is evidence of this. If we could accept this we would realise that we should not blame ourselves. We should also see that when we blame ourselves we simply add another layer of negative thoughts thus adding to our distress.

Within this framework the aim of helping is to encourage the person to focus on their current thinking and to rediscover their choices. This raises a number of questions about the terms used to describe distress and the helping process. Should the distress be called a ‘condition’ and be based on a stock take of their ‘symptoms’? Should the helping be called ‘therapy’ that starts with an ‘assessment’ and takes place in a ‘consulting room’ or ‘clinic’? Should the helping offer ‘treatment techniques’ or claim to be ‘evidence-based’? Could the dialogue between helper and helped focus more on what people naturally discover for themselves about thinking and behaving in the course of living rather than so-called evidence-based techniques?

The answers one chooses to these questions will define any power differential and ‘distance’ between helper and helped and will have an influence on the extent to which the distressed person both feels empowered and is empowered.

I have worked as a Clinical Psychologist for 38 years. In spite of this two of my daughters are now qualified Clinical Psychologists.
I have worked in a variety of settings in the NHS, with a number of companies, a university health centre, in health education, with self-help groups. I also act as an expert witness. My main interest is in the words and ideas available to us to describe distress and how these can adversely shape our experience.

I am both a (retired/disabled) psychologist and a user of mental health services in the US. My first reaction to this article was that while the intentions are good, the ideas are not new and do not fully reflect clinical practice nor underlying theory.

The biopsychosocial model, in particular, is broader than presented in the article, in that the model’s components are seen as interactive, nonlinear, ecological (including not only sociocultural factors surrounding the person, including interpersonal, economic, sociopolitical and religious factors, but also both the internal – biological and psychological – and external – built and natural – environments) and dynamic. It is a counterpoint or alternative to the medical model.

CBT is but one approach that can come under the biopsychosocial model’s umbrella, along with existential, dialectic, expressive and systems-focused therapies. They are client-focused rather than clinician-focused therapies, and when done by appropriately trained ( and often eclectically trained) therapists, the clinician is more of a guide or co-creator of change than all-knowing “doctor” deciding what the “patient’s” problems are and how they should be addressed – or prescribing homework just because they can, rather than because the homework fits a client-agreed treatment goal. Medication may be part of treatment, especially when the client wouldn’t be able to fully participate in therapy otherwise, but it is not seen as being the primary way to “cure what ails them.”

In particular CBT can empower the client through determination of client goals for therapy, and through use of an outcomes-oriented treatment plan developed with the client, rather than by the therapist and presented to the client. In the US, in most community clinics and many private practices, this is true even if the therapy used deviates from “strict” CBT protocols. While the assessment process is far from empowering and is often done by judgmental paraprofessionals using required questions and tasks, once the client and therapist meet, the client can tell the therapist if the assessment and presented results left out important issues, misstated client responses, occurred on a day when the client felt more tired or distracted than usual, or otherwise felt incomplete or incorrect to the client. This then presents an opening to discuss client needs and why they have come for therapy, leading to the development of the client’s goals stated in the outcomes-based treatment plan. This might take several sessions, but the therapist also can use that discussion and planning as part of helping the client see their role in ending up where they are without blaming the client or laying it on long-ago history.

Unfortunately, the medical model rules treatment from the perspective of who decides what meds the patient needs, giving thev appropriate diagnostic code to justify it, thus labeling and disempowering the patien. The medical model leaves the non-medical therapist stuck with undoing the harm done to the client in interactions with clinic (or hospital or referral) medical directors or psychiatrists who decide what the client/patient problem is and what meds they should or can or can’t have; insurance companies that then use the medical model to determine what they will or won’t pay for; and medical records containing this medical determinism that follow the client around with no real way to change or remove incorrect information. And the client-focused therapist working under a biopsychsocial model who recognizes this reality may need to include related issues in the initial or later sessions with the client, for whom some things do feel – and may actually be – out of their control, no matter how hard they try to control their reaction and thinking.

Too many practitioners forget “first, do no harm” under the in loco parentis medical model approach to mental illness and forget that wellness is the goal for the client!

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